Necessary Hubris


A key component of the culture of all surgery training programs is the morbidity and mortality conference. Even as neophyte surgeons, we are taught to critically analyze and accept responsibility for our failures. Historically, this conference was used to bring the accountable surgical resident to his or her knees by hypercritical and accusatory comments from the attending surgeons. Most institutions now favor education over humiliation, with the understanding that most critical decisions are made by attending surgeons rather than residents. Well-conducted morbidity and mortality (M and M) conferences ascribe most poor outcomes to either judgmental or technical errors by the operating surgeon or team. Only after a detailed analysis fails to find such miscalculations can Providence be blamed.

As difficult as it was to realize that my actions as a surgical trainee had contributed to the demise of a patient, dealing with surgical failure became progressively more trying during my 31 years as an attending surgeon. As I gained more experience and greater surgical wisdom, I expected more of myself. The awareness of my patients’ complications and deaths occupied more of my waking and sometimes sleeping hours. Even when no specific technical or judgmental error of mine came to light during the M and M conference or after a detailed replay of the case in my own mind, the adverse outcome could not easily be washed away. Especially challenging were major complications such as a pancreatic fistula or sepsis that resulted in a prolonged hospital stay. Daily visits with the affected patients were vivid reminders of imperfect operations and tended to amplify my sense of failure.

Although most patients and their families were remarkably resilient and accepting of an adverse outcome, occasionally I could detect a subtle hint in their body language or demeanor suggesting doubt as to whether they had selected the best surgeon. This tended to occur when a complication was followed by other complications over a prolonged period of time. My wife always knew when I was carrying such a burden because of my increased irritability and occasional depressed moods at home.

I’m not implying that I was pathologically depressed or haunted by fear of failure during much of my surgical career. My occasional failures were offset by many more successful outcomes that brought me considerable satisfaction and joy. I also do not intend this to be a mea culpa for expiation of my past sins. I suspect that most surgeons have had similar feelings of failure and inadequacy intermittently throughout their careers. Presumably we all strive for perfection that, unfortunately, is impossible to attain. A common expression among us is "a surgeon who has no complications is a surgeon who doesn’t operate."

I admire the many surgical pioneers who faced failure after failure and death after death, but persisted, thereby advancing our field. Hubris, defined as excessive pride, self-confidence, or even arrogance, must have been a defining characteristic of many of them. Hubris is usually a pejorative word, but I suspect that many of our innovative forebears possessed enough of it to continue striving through a dark cloud of repeated failures, until they could demonstrate success with a new and improved approach to surgical disease.

I would like to highlight the remarkable accomplishments of two pioneers who persisted in the face of failure and opened new vistas of surgery that have benefited millions of patients. Theodor Billroth, a 19th-century Viennese surgeon and the father of abdominal surgery did the first successful esophagectomy. However, several of his contemporaries had attempted what was considered the technically more difficult gastrectomy, and their patients had all died soon after surgery. The consensus opinion among 19th-century surgeons was that gastrectomy was an insurmountable technical hurdle. Although Wikipedia is my only source, it reports that Billroth was stoned in the streets of Vienna after it was discovered that he had unsuccessfully attempted a gastrectomy. However, Billroth successfully performed a partial gastrectomy for cancer in 1881. This single operation, more than any other, paved the way for the future of abdominal surgery.

Eighty years later and after extensive animal experimentation, Thomas Starzl initiated his clinical experience with liver transplantation. None of his first seven patients survived longer than 23 days. Starzl persisted, the operative technique was refined, the immunosuppressive regimen was improved, and all of the subsequent seven patients survived a minimum of 2 months. The definitive therapy for end-stage liver disease was born.

My admiration and respect go out to these two surgical pioneers and the many others who have advanced our science despite initial lack of success that often led to criticism and skepticism. Without their creativity, persistence, courage, and yes, hubris, the surgery of yesterday would still be the surgery of today.☐

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